Vestibular Schwannoma Screening
David Kaylie, MD, MS, associate professor of head and neck surgery at Duke University in Durham, N.C., said there is not enough evidence to make a firm recommendation on which patients with asymmetric sensorineural hearing loss should be screened for vestibular schwannoma (VS), typically found in about 5% of this patient group. But there are some data suggesting that a threshold of 3 kHz could be considered. He presented the findings from a review by Amar Gupta, MD, and Edwin Monsell, MD, PhD, of Wayne State University in Detroit (Laryngoscope. 2018;128(9):1990-1991).
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April 2020One study of 74 patients with VS (Otol Neurotol. 2009;30:515-521) found that the greatest asymmetry was seen at 3 kHz, and the researchers suggested that an asymmetry of at least 15 dB at 3 kHz should be considered for screening. This recommendation—known by physicians in the field as the “rule of 3,000”—was also a suggestion that stemmed from another study. But, as Dr. Kaylie noted, the variation in asymmetry from the first test to a re-test was about 5 dB, which could affect the screening results. Another consideration is that 3 kHz can be an awkward standard because it is an inter-octave frequency that is not always tested, he said.
All things considered, Dr. Kaylie said, 3 kHz should not be used as a sole measure.
“Many other factors may also influence the decision to get an MRI,” he said, including tinnitus and asymmetric discrimination.
Epinephrine for Endoscopic Endonasal Surgery
Edward Kuan, MD, assistant professor of otolaryngology-head and neck surgery at the University of California, Irvine, said that topical epinephrine is a safe option for maintaining hemostasis during endoscopic endonasal surgery. The literature shows just two adverse events with the agent across 4,398 cases—a 0.05% rate (Am J Rhinol Allergy. 2010;24(2):140-142; Int Forum Allergy Rhinol. 2016;6:135-139; Int Forum Allergy Rhinol. 2015;5:1118-1123).
But physicians and surgeons should use caution with epinephrine in patients with a cardiovascular history and in young children, he said. Dr. Kuan added that the pledgets that are used should be wrung out so that too much of it isn’t applied. It’s critical, he said, to properly label solutions of different concentrations to prevent accidental administration.
Steroids for Facial Nerve Function
Maie St. John, MD, PhD, professor and chair in the department of head and neck surgery at the University of California, Los Angeles, said that the existing evidence doesn’t support using steroids peri-operatively to help with facial nerve function.
“No investigation has demonstrated a positive correlation of corticosteroids on improved facial nerve function,” she said. That is the case for both immediate post-operative outcomes and recovery rates in long-term follow-up.
A systematic Cochrane Review, which included two placebo-controlled randomized trials, for instance, found no advantage for corticosteroid use in immediate facial nerve function recovery, nor in how fast patients respond, Dr. St. John said. But she did point out that no adverse events stemmed from their use (World J Clin Cases. 2015;3(2):180-185). The analysis was limited, however, because it was challenging to make comparisons between the studies. “Future research should focus on well-designed randomized prospective trials,” she said.